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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608466
Report Date: 02/25/2025
Date Signed: 02/25/2025 01:49:30 PM

Document Has Been Signed on 02/25/2025 01:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BELMONT VILLAGE ENCINOFACILITY NUMBER:
197608466
ADMINISTRATOR/
DIRECTOR:		ABIGAIL TRAXLERFACILITY TYPE:
740
ADDRESS:15451 VENTURA BLVDTELEPHONE:
(818) 788-8870
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91403
CAPACITY: 150CENSUS: 101DATE:
02/25/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Abigail TraxlerTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Barutyan conducted a Case Management - Deficiencies visit as information received during the investigation of Complaint Control #29-AS-20240417163437 confirmed an error in accounting. The purpose of the visit is to issue a citation for a deficiency observed during the subsequent complaint investigation.

During the visit on 02/25/2025, LPA reviewed Resident #1 (R1)’s ledger from 01/01/2017 – 12/31/2024. R1’s admission agreement signed and dated on 12/30/2017 states under “termination by resident” that a resident “may terminate this Agreement at any time, with or without cause, by giving the Executive Director thirty (30) days’ prior written notice of termination” and the resident “will continue to be responsible for [their] full Monthly Fee until the thirty (30) day period has expired.” The facility was notified by R1’s responsible party on 11/30/2022 that R1 will move out of the facility, meaning that the thirty (30) day period would be from 11/30/2022 – 12/30/2022. R1 moved out of the facility on 12/03/2022. R1 was charged for the period of 12/03/2022 – 01/03/2023, totaling $1,059.15 after accounting for the full December 2022 rent of $11,575.00 and $125.00 recurring total incontinence management supplies (TIMs) fee charged on 12/01/2022. Therefore, the remaining balance of $1,059.15 ($9.93 TIMs fee + $919.66 monthly rent) is for the three (3) additional days in January 2023 which was counted for thirty (30) days after R1 moving, 12/03/2022. However, R1 moved out within the thirty (30) day notice was that was received by the facility on 11/30/2022. R1 was overcharged in error for the period of 12/31/2022 – 01/03/2023.

Report Continued on LIC 809-C.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/25/2025 01:49 PM - It Cannot Be Edited


Created By: Angela Barutyan On 02/25/2025 at 01:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELMONT VILLAGE ENCINO
FACILITY NUMBER: 197608466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2025
Section Cited
CCR
87468.2(a)

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Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: This requirement is not met as evidenced by:
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The facility did not receive payment for the 01/01/2023-01/03/2023 balance of $1,059.15. ED stated they will issue a check for the balance owed, $377.42, and have it mailed to R1/responsible party of R1 and submit proof to CCL by 03/11/2025.
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Based on record review, the licensee did not comply with the section cited above as Resident #1 (R1) was wrongfully overcharged a total of $1,436.57 which poses a potential personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Angela Barutyan
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELMONT VILLAGE ENCINO
FACILITY NUMBER: 197608466
VISIT DATE: 02/25/2025
NARRATIVE
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Report Continued from LIC 809.

While R1/responsible party of R1 did not pay the wrongfully charged $1,059.15 balance from 01/01/2023 – 01/03/2023, R1 paid the full monthly fee of $11,575.00 + $125.00 TIMs fee for December 2022 on 12/01/2022, which includes payment for the day of 12/31/2022. The $1,059.15 balance was dropped on 04/30/2024. The facility owes R1/responsible party of R1 payment for the day of 12/31/2022, a total of $377.42 ($373.39 daily fee + $4.03 TIMs fee) as this falls outside of the thirty (30) day period of the move out notice provided on 11/30/2022.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Administrator was informed that failure to correct deficiency may result in civil penalties.

Exit interview was conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC809 (FAS) - (06/04)
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